Table Of Contents
616.462
P30DBM
2009
1
DIABETES:
The Burden Montana
in
MontanaStateLibrary
3 0864 1005 8577
1
Front cover:
Images modified from "Blacl< Butte and Lupines" © Todd S. Harwell 2007.
ACKNOWLEDGEMENTS
This report was prepared by the Montana Diabetes Project, Chronic Disease Prevention and Health
Promotion Section, Public Health and Safety Division, Montana Department of Public Health and Hu-
man
Services.
The following individuals contributed to the development and preparation of this report;
Taryn Hall, MPH
MD
Dorothy Gohdes,
MPH
Carrie S. Oser,
Helen Amundson, RN, BSN, CDE
Todd S. Harwell, MPH
Steven D. Helegerson, MD, MPH
The authors would like to give special thanks to the following individuals and organizations for their
technical assistance and data contributions to this report::
Montana Behavioral Risk Factor
Surveillance System (BRFSS)
• Susan Cummings, BSN, CPHQ,
BRFSS Coordinator
Montana Office ofVital Statistics
• David Fulgham, PhD, Mortality
Statistician
• Bruce Schwartz, MA, MPA, Re-
search Specialist
• Cody Custis, MA, Natality Statisti-
cian
Montana Medicaid program
Montana HospitalAssociation
EXECUTIVE SUMMARY
Prevalence of Diabetes has increased in Montana.
• Almost 48,000 adults in Montana have diagnosed diabetes —6.4 percent ofadults.
• The rate has been increasing steadily from 2.8 percent in 1990.
• The rate of diabetes in American Indians is 2.5 times higher than the rate in the general population and
has also increased.
Cardiometabolic Risk Factors are common in those at-risl< for diabetes and heart disease.
• Twenty-one percent ofall adults were obese according to their reported height and weight.
• Thirty percent ofadults without diabetes reported high cholesterol levels.
• Twenty-two percent ofadults without diabetes reported high blood pressure.
• Persons with diabetes reported high cholesterol and high blood pressure at least twice as frequently as
those without diabetes.
Diabetes in Pregnancy is an additional public health burden.
• Almost 3 % ofall births listed some form ofdiabetes with gestational diabetes listed as the major form.
• Montana Indian women had twice the rate ofdiabetes in pregnancy compared to whites.
• Women with a history of gestational diabetes were twice as likely to have pregnancy related diabetes in a
subsequent pregnancy up to fiveyears later compared to women without gestational diabetes.
Diabetes Care comprehensive.
is
• Sixty percent of Montana adults with diabetes reported receiving diabetes education classes, and 67 per-
cent monitored their blood sugar at least daily.
• Sixty- seven percent had received Ale testing twice in the past year; 72 percent an annual eye exam, and
80 percent an annual foot exam.
• Two-thirds were currently immunized with a yearly flu shot and one pneumovax.
Diabetes Complications are widespread.
• Hospital discharge rates for diabetes increased in recentyears to 136 per 10,000.
• Diabetes contributed to 45 percent ofnew and existing ESRD in Montana and 66 percent of
non-traumatic lower extremity amputations.
• Hospital discharge rates for stroke and heart disease with diabetes in Montana were lower than compara-
ble US rates.
Diabetes Mortality is higher in Montana Indians compared to whites.
• The age-adjusted diabetes mortality rate was 23 per ]00,000 with rates in Montana Indians three times
higher than that of non-Indians.
TABLE OF CONTENTS
Summary
Executive
Introduction
Diabetes 3
Montana 4
Chapter Prevalence 5
I :
Chapter 2: Cardiometabolic Risk Factors 7
Overweight and obesity 8
High blood pressure 9
High cholesterol 9
Chapter 3: Diabetes During Pregnane
Chapter 4: Care Indicators
Diabetes Education 13
Self-monitoring blood glucose 13
HbAlc
testing 14
Dilated eye exams 15
Foot exam 15
Annual influenza vaccination 16
Pneumococcal immunization 16
Chapter Complications
5:
Hospitalization
Chronic kidney disease and end-stage renal disease
Cardiovascular disease
Lower extremity amputations
Chapter 6: Mortality
Discussion and Conclusion
Appendix
Methods, data sources and limitations
References
INTRODUCTION
Diabetes
Diabetes is complex chronic metabolic disorder characterized by high blood sugarwhich, in its various forms,
can affect people ofall ages. The progressive complications ofdiabetes include blindness, amputation, kidney
failure and nerve problems.' Diabetes markedly increases the risk of heart disease and stroke.' Type 1 diabe-
tes, generally diagnosed during childhood or adolescence, is an autoimmune disease where the immune sys-
tem destroys insulin-making cells ofthe pancreas. Type 1 diabetes makes up about 5 percent ofthe overall
burden ofdiabetes.^ The much more common form is type 2 diabetes which is associated with obesity and
insulin resistance. Type 2 diabetes is most frequently diagnosed during adulthood and contributes to 90 to 95
percent ofthe diabetes burden.^ Type 2 diabetes is highly prevalent in certain populations including Ameri-
can Indians. With increasing rates ofobesity in the US, type 2 diabetes is now being diagnosed in children
and adolescents.
Diabetes in pregnancy is also a serious and growing challenge. High blood sugars from pre-existing diabetes
ofeither type are associated with serious congenital malformations. Gestational diabetes can develop during
pregnancy but resolve after delivery.^ Any form ofdiabetes in pregnancy is associated with obstetrical compli-
cations at deliveryand potential problems for the newborn. Women who develop gestational diabetes are at
very high risk ofdeveloping type 2 diabetes postpartum, and children from any diabetic pregnancy are at risk
for obesityand type 2 diabetes at a young age.'' Thus, diabetes and its complications present a major clinical
and public health challenge, and preventing type 2 diabetes through diet and exercise has become an urgent
priority for many communities.''
INTRODUCTION
Montana
Montana is the fourth largest state in the nation with a land sx^d of 145,552 square miles and is among the
most rural. The most recent estimate (2006) of Montana's total population is 944,632, resulting in a popula-
tion density ofjust over six persons per square mile/ The majority of the states population resides in western
Montana, with the notable exception of Yellowstone County. The population density of western Montana is
12 persons per square mile compared to 4 persons per square mile in eastern Montana. Forty-nine of Mon-
—
tana's 56 counties are classified as frontier counties.^ Seven counties are classified as small urban counties
62 percent ofMontana's population reside in one ofthese counties.
The median age is 39.5 years and 14 percent of Montana residents sxe 65 years of age or older.' Over 90 per-
cent of Montana's population is white. American Indians comprise 6.8 percent of Montana's population and
are the state's largest minority group.' Montana has 7 American Indian reservations and 12 tribes are formally
represented in the sovereign tribal governments on these reservation.
Montana is also one of the poorest states in the nation. Montana ranked 44th in the nation in 2006 with a
—
median household income of $39,821 17 percent less than the US median household income ($48,201).'°
In terms of wages, in 2003, eight of the ten poorest counties in America were located in Montana's frontier
counties." In 2006, the Behavioral Risk Factor Surveillance System (BRFSS) found that 17 percent of all Mon-
tanans reported having no health care coverage. Uninsured adult Montanans were likely to be younger and
report lower income and less education than adults with health care coverage (data not shown). ^
Figure 1-1: American Indian reservations
and small urban counties in Montana.
Legend
r//^ IndianReservation
SmallUrbanCounty'
I I
FrontierCounty
I I
^
PREVALENCE
Figure 1-1- Prevalenceofdiabetes forall Montanans, Montana Indians
Since 1990, diabetes prevalence in the and the us, 1990 to 2006.
US and Montana has continued to 20
rise. In 2006, 6.4 percent of Montana ^9
adults reported having diabetes—
about 48,000 adults. The prevalence *• - - -. . - -»*
15
of diabetes in adults in Montana in-
creased from 2.8 percent in 1990 to ••'
c
6.4 percent in 2006. In the United 0o)
States, the prevalence of diabetes was 0)
slightly higher than the rate in Mon- CL * _*—J
tana, and the US rates also increased ^
from 4.9 percent in 1990 to 7.5 per- /
cent in 2006. (Figure l-I)
1990 1992 1994 1996 1998 2000 2002 2004 2006
Montana US • MTAl
Risk Factors for Diabetes Datasource: MontanaBRFSS.MontanaDPHHS,HealthPlanningSection,1990-2006.
MontanaAmericanIndianadapted-BRFSS,MontanaDPHHS.1999,2001,2003and2005.
Race 'Questionchiangedin 1994to excludefemaleswithigestationaldiabetes.
In 2005, 18.7 percent of Montana Indian adults (about \Q,QQQ] reported a diagnosis of diabetes; about 2.5
times greater than the general Montana population. From 2000 to 2005, prevalent diabetes increased about
50 percent in Montana Indians from 12.2 percent in 1999 to18.7 percent in 2005. Though American Indians
represent only 6.8 percent of the Montana population, they contributed about 25 percent of prevalent diabe-
tes cases in 2005.
Age
The prevalence of diabetes increases with increasing age. For 2006, estimated prevalence of diabetes in the
youngest adult age groups, 18 to 24 and 25 to 34 year old, was 0.9 percent [95% CI: 0—2.2] in both. About 4
percent (3.7 [2.2-5.2]) ofadults aged 35 to 44 and 5.5 [3.7-7.3] percent of adults aged 45 to 54 had diabetes.
Diabetes prevalence was twice as high ( 1 1 .7 [9.6-1 3.8]) in those aged 55 to 64 years of age and was highest
( 14.0 [12.0-16.0]) in adults over 65 years in age.
From 1 995 to 2006, the prevalence of diabetes in the youngest adult age groups remained at about 0.9 per-
cent. Prevalence in the oldest three age groups, 45 to 54 years old, 55 to 64 years old and greater than 65
years old doubled between 1996 and 2001. The prevalence in the 45 to 54 and the 55 to 64 year old age
groups has remained constant in the most recent years. However, since 2003, the prevalence in persons
greater than 65 years ofage continued to increase. Prevalence in 35 to 44 year olds also doubled, increasing
from 1.7 percent [0.5-2.9] in 1999 to 3.3 percent [2.0-4.6] in 2004, but remaining at about 3.3 percent in 2005
and 2006. (Data not shown)
d
PREVALENCE
dDlieabeatgeesdococruresldecrolym.monAdluyltisn tohveermi4d5- FMiognutraen1a-2.20P0e6r.centageofpersons with diabetes from each adult agegroup.
years of age comprised 86 percent of
the burden of diabetes in Montana in 25-34 year olds
2006. Middle aged people, those 45 to 1,000
18-24 year olds
64 years old, accounted for 47 percent 2%
850
of the diabetes burden, while the eld- 2% 35-44 year olds
erly (65 years or older) accounted for 39 1 r 4,500
percent. (Figure 1-2) '^C 10%
65+ year olds ^^^^^^g
^^^^Hf y^\
^ 45-54 year olds
^^^H^
39% \ 7,600
^ 7%
1
55-64 year olds
13,500
30%
CountyofResidence
Figure 1-3. County Level Estimates of Diabetes Prevalence •
Percentage ofAdults in Montana by Quartiles, 2005
In 2005, there was a strong association
between diabetes prevalence and the
county of residence. Counties with the
lowest diabetes prevalence tended to
cluster along the mountain ranges in
western Montana. All of the counties
containing major population centers
were among the lowest diabetes preva-
lence. Counties in eastern Montana
tended to have higher prevalence of
diabetes. With a few exceptions, coun-
ties with the highest diabetes preva-
lence included an Indian reservation.
(Figure 1-3)'^
CARDIOMETABOLIC FACTORS
RISK
Metabolic Syndrome is defined as a Table 2-1;ATP 21 Clinical identification ofthe Metabolic Syndrome''*
clustering of risk factors that confer an
increased risk for cardiovascular dis-
Risk Factor Defining level
ease. These risk factors include: ab-
dominal obesity, elevated blood sugar, Abdominal obesity, given as a waist
high triglyceride levels, low HDL and circumference
high blood pressure. Individuals with
Metabolic Syndrome, whose blood Men > 40 in (> 102 cm)
sugar values are not in the diabetic
range, are also known to be at very Women > 35in (>88cm)
high risk for type 2 diabetes.''' Thus HDLcholesterol
the term cardiometabolic risk encom-
Men <40 mg/dL
passes a set of risk factors for both type
2 diabetes and cardiovascular disease Women <50 mg/dL
stemming from obesity and insulin re-
sistance. Most importantly, intensive
lifestyle intervention can have inde- Triglycerides > 50 mg/dL
1
pendent and beneficial effects on each
Fasting glucose > 00 mg/dL
risk factor thus reducing the risks of 1
type 2 diabetes and cardiovascular dis- Systolic > 130 mm Hg
Blood pressure
ease.'^ Diastolic > 85 mm Hg
Reducing cardiometabolic risk factors is
an important clinical and public health
challenge in Montana. There is a Table 2-2: Weightcategories by body mass index (BMI)
higher prevalence of obesity, high cho- BMI range
lesterol and high blood pressure in
people with diabetes than in people Normal 18-24.9 kg/m^
without diabetes, contributing to the Overweight 25-29.9 kg/m^
increased risk of cardiovascular disease
in people with diabetes. And many Obese > 30 kg/m^
Montanans who are overweight, hy- Clinically obese 35-39.9 kg/m^
pertensive and have dyslipidemia are at
risk for type 2 diabetes. Morbidly obese > 40 kg/m^
